Dysautonomia-MVP Center2470 Rocky Ridge Road, Ste 200

Birmingham, AL 35243

Dysautonomia-MVP Center

We look forward to seeing you. Please call us if you have any further questions. (205) 286-3200 / (205) 286-3201 Fax.

VISIT OUR WEBSITE AT WWW/MVPCTR.COM

Dysautonomia-MVP Center2470 Rocky Ridge Road, Ste 200

Birmingham, AL 35243

staff@mvpctr.com

Dysautonomia-MVP Center

Dysautonomia-MVP Center

Dysautonomia-MVP CenterDysautonomia-MVP Center

Dysautonomia-MVP Center

REV. 3/6/15PATIENT INFORMATION

Email:_______________________________________________________________________________________________________

Dysautonomia-MVP Center2470 Rocky Ridge Road, Ste 200

Birmingham, AL 35243

REV. 3/6/15

Dysautonomia-MVP Center2470 Rocky Ridge Road, Ste 200

Birmingham, AL 35243

Phone 205-286-3200 Fax 205-286-3201

staff@mvpctr.com

Dysautonomia-MVP Center

2470 Rocky Ridge Road, Ste 200

Birmingham, AL 35243

Phone 205-286-3200 Fax 205-286-3201

D ys autonomia-MVP C enter

(205) 286-3201

Dysautonomia-MVP Center2470 Rocky Ridge Road, Ste 200

Birmingham, AL 35243

staff@mvpctr.com

REV. 3/6/15

Dysautonomia-MVP Center

Any physician, staff, employee or representative of Dysautonomia-MVP Center has my permission to discuss my account and medical conditions which may include symptoms, treatments, diagnosis, test results, medications or any other type of protected health information with the following persons:

Dysautonomia-MVP Center2470 Rocky Ridge Road, Ste 200

Birmingham, AL 35243(205)-286-3200

3/06/15

(B) 3/06/15

Effective January 1, 2012, the Dysautonomia-MVP Center will

have a charge for a patient who cancels or does not show

for their appointment.